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Back  RFI # 2210: Pat Resp In Unbundled Codes

Formal vs. Informal Help Informal Formal

Submitter

Andrew Lee

Description

We have a payer that is unbundling a procedure with one unit, and a 50 modifier into two payments. They are putting PR codes on each payment.The example in the spec doesnt have any Patient Responsibility.

SVC*HC:20610:50*420*89.05**1
DTM*472*20170320
CAS*CO*45*308.69
CAS*PR*2*22.26
REF*6R*2672577.1991
AMT*B6*111.31

SVC*HC:20610*0*44.52**1*HC:20610:50*0
DTM*472*20170320
CAS*PR*2*11.13
CAS*OA*94*-55.65
REF*6R*2672577.1991
AMT*B6*55.65

The example for bundling shows the PR2 only on the initial SVC. However the Unbundling example is without PR. In the example above, the payer is sending back PR2's for both procedures.

Is their use of the PR codes compliant with the guidelines?

Submitter Assigned Keywords

Unbundle

Response

The bundling and unbundling examples in the TR3 are only single examples of one bundling and unbundling scenario. They do not encompass every possible unique scenario. There is nothing in the TR3 that restricts the use of a CAS*PR adjustment in bundling or unbundling other than the fact that balancing must be maintained for all service lines.
Submission 4/27/2017
Status Date 6/7/2017
Status F - Final
Primary References
Document 005010X221
Section1.10.2.6